Board Review

A 38-year-old woman is evaluated during a routine examination. She is a mother of two children and works full time at a high-stress job. She smokes 10 cigarettes daily, eats fast food three times per week, and drinks two alcoholic beverages most nights. She does not exercise. Family history is noncontributory. She takes no medications.

On physical examination, the patient is afebrile, blood pressure is 122/76 mm Hg, and pulse rate is 80/min. BMI is 26. The remainder of the physical examination is normal.

Which of the following interventions will have the largest impact on this patient's health?

A) Decrease alcohol consumption

B) Exercise 30 minutes daily, 5 days per week

C) Healthful diet including fruits and vegetables

D) Smoking cessation

E) Stress management and relaxation techniques

Answer: D - Smoking cessation

Objective: Identify the relatively large impact of smoking cessation on improving health.

Key Point

The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users.

This patient would most benefit from smoking cessation counseling. Cigarette smoking increases the risk of cancer, heart disease, stroke, and lung disease and is the leading preventable cause of death in the United States. Quitting smoking is the single most important thing that smokers can do to improve their quality and quantity of life. Smoking cessation before age 40 years reduces the risk of death associated with continued tobacco use by approximately 90%. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users. Behavioral counseling for smoking cessation in primary care settings has been found to improve quit rates and sustained abstinence at 1 year. Even minimal in-office interventions, defined as less than 3 minutes in duration, are effective in improving smoking cessation rates.

A meta-analysis suggested that women who consume an average of two or more alcoholic drinks per day had an increased mortality rate compared with nondrinkers; therefore, this patient may benefit from counseling regarding reducing her alcohol consumption. Nonetheless, the benefit of brief intervention for smoking cessation is still likely to be more impactful in this patient.

Exercising and eating a healthful diet both have a significantly positive impact on health and have been strongly linked with decreased incidence of cardiovascular disease. However, the effect of behavioral counseling in promoting healthful diet and physical activity in adults without known cardiovascular disease, hypertension, hyperlipidemia, or diabetes is small. Given small potential effect, time limitations, and opportunity costs, the USPSTF recommends offering dietary and exercise behavioral counseling based only on individual patient circumstances. In this patient, smoking cessation counseling will have a greater benefit than counseling that promotes a healthful diet and physical activity.

Stress reduction and relaxation techniques have the potential to improve this patient's health; however, the health benefits of smoking cessation are likely to be greater.

Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013 Jan 24;368(4):341-50. Link Out